Postoperative fever

Antimicrobial prophylaxis is not indicated for horses undergoing general anaesthesia for elective orthopaedic MRI

BACKGROUND

Post-anaesthetic fever is a known complication of general anaesthesia, however, its incidence in horses undergoing elective magnetic resonance imaging (MRI) is unknown.

OBJECTIVE

To determine the incidence of post-anaesthetic fever in horses undergoing elective orthopaedic MRI and determine whether prophylactic antimicrobial therapy would be associated with a reduction in the incidence of post-anaesthetic fever. We hypothesised that prophylactic antimicrobials would be associated with a reduction in the incidence of post-anaesthetic fever.

STUDY DESIGN

Retrospective cross-sectional study.

METHODS

This retrospective study included 791 elective orthopaedic MRIs in systemically healthy horses between June 2006 and March 2020 that recovered from general anaesthesia and did not undergo surgery or intensive medical therapy soon after recovery. Potential factors associated with post-anaesthetic fever were evaluated using multivariable logistic regression. Case signalment, travel time, preanaesthetic haematology and fibrinogen abnormalities, use of prophylactic antimicrobials, peri-anaesthetic nonsteroidal anti-inflammatories, anaesthesia time and recovery time were all evaluated for association with post-anaesthetic fever.

RESULTS

Of 791 MRI cases, 44 (5.6%) developed a post-anaesthetic fever. Horses that received prophylactic antimicrobials were [odds ratio (OR) 3.8, 95% confidence interval (CI) 1.98-7.46; p ≤ 0.001] more likely to develop a post-anaesthetic fever than those that did not receive antimicrobials. Young horses (1-4 years of age) were (OR 2.8, 95% CI 1.26-6.17; p = 0.01) more likely to develop fever compared with adult horses (≥5 years of age).

MAIN LIMITATIONS

Limitations of this study pertain to retrospective analysis including nonrandomised case selection and incomplete data records.

CONCLUSIONS

While fever may indicate infection, the majority of early post-anaesthetic fevers resolved before discharge from the hospital with no identified cause. The use of prophylactic antimicrobials to reduce the risk of post-anaesthetic fever for elective MRI is not supported by this study.

Early Postoperative Fever and Atelectasis in Patients Undergoing Upper Abdominal Surgery

BACKGROUND

Atelectasis is a common complication after upper abdominal surgery and considered as a cause of early postoperative fever (EPF) within 48 hours after surgery. However, the pathophysiologic mechanism of how atelectasis causes fever remains unclear.

STUDY DESIGN

Data for adult patients who underwent elective major upper abdominal surgery under general anesthesia at Seoul National University Hospital between January and December of 2021 were retrospectively analyzed. The primary outcome was the association between fever and atelectasis within 2 days after surgery.

RESULTS

Of 1,624 patients, 810 patients (49.9%) developed EPF. The incidence of atelectasis was similar between the fever group and the no-fever group (51.6% vs 53.9%, p = 0.348). Multivariate analysis showed no significant association between atelectasis and EPF. Culture tests (21.7% vs 8.8%, p < 0.001) and prolonged use of antibiotics (25.9% vs 13.9%, p < 0.001) were more frequent in the fever group compared to the no-fever group. However, the frequency of bacterial growth on culture tests and postoperative pulmonary complications within 7 days were similar between the two groups.

CONCLUSIONS

EPF after major upper abdominal surgery was not associated with radiologically detected atelectasis. EPF also was not associated with the increased risk of postoperative pulmonary complications, bacterial growth on culture studies, or prolonged length of hospital stay.

Reduction in the Duration of Postoperative Fever during the COVID-19 Pandemic in Orthopedic and Traumatic Surgery Due to PPE and Cautions

The Italian government on the 8th of march in response to the increased global prevalenceof severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) stated a national quarantine. In this period the absence of rapid and sure screening tests for COVID-19 made necessary more attention for presence of fever in hospitalized patients, like continuous use of surgical, FFP2, and FFP3 masks (PPE) by nurses, physicians, and patients; moreover, patients visits were restricted. In this period, during the daily activities in our orthopedic department we observed an empirical decreased incidence of post-operative fever in patients admitted for trauma surgery. The aim of this study is to compare the prevalence of post-operative fever in this period with the same period in 2019. We analyzed the presence of post-operative fever in 110 patients admitted in 2020 and 129 admitted in 2019. The results show a significant decrease of the prevalence and duration of post-operative fever in patients admitted in 2020. This study evidenced that the use of PPE and limitation in external access to the hospital decrease postoperative fever in hospitalized patients undergone surgery for fracture.

Changed inflammatory markers after application of 4DryField PH for adhesion prevention in gynecological surgery

Introduction

The development of peritoneal adhesions and the effects of different antiadhesion agents on such mechanisms are not fully understood. Temporary rises of the C-reactive protein (CRP) level have been reported after antiadhesion agent application. We present the changes of inflammation markers observed after use of a starch-based polysaccharide certified for adhesion prevention and hemostasis 4DF (4DryField^® PH).

Method

Retrospective comparative analysis of inflammation markers in 40 patients undergoing laparoscopic adhesiolysis with or without adhesion prophylaxis was conducted. Statistical comparisons were performed by means of paired or unpaired t tests (for normally distributed continuous data), Wilcoxon matched pairs signed-rank tests or Mann–Whitney tests (for not-normally distributed continuous data), Mantel–Cox tests (for continuous data describing time intervals), and Fisher’s exact tests (for discrete data).

Results

The maximum post-operative CRP level was significantly elevated in the 4DF group (87 vs. 29%; p < 0.001), whereas leukocyte concentration and body temperature did not differ between groups. No signs of infection were detected in any of the patients and CRP levels spontaneously dropped to normal values within few days. No side effects or complications were observed in both groups. In second-look surgeries performed for other diagnoses 1–56 weeks after the first interventions, no remnants of 4DF or any peritoneal inflammatory reactions were observed.

Conclusion

The starch-based polysaccharide 4DF can be considered safe and does not induce inflammatory reactions of clinical significance. Further studies regarding 4DF degradation are recommended and, apart from macrophage migration, could also examine corresponding markers such as IL-6 and PCT.

Management of Postoperative Fever in Adult Cardiac Surgical Patients

Postoperative fever after cardiac surgery is a common occurrence. Most fevers are benign and self-limiting resulting from inflammation caused by surgical trauma and blood contact with cardiopulmonary bypass circuit resulting in the release of cytokines. Only a small percentage of time is postoperative fever due to an infection complicating surgery. The presence of fever frequently triggers a battery of diagnostic tests that are costly, could expose the patient to unnecessary risks, and can produce misleading or inconclusive results. It is therefore important that fever be evaluated in a systematic, prudent, clinically appropriate, and cost-effective manner. This article focuses on the current evidence regarding pathophysiology, incidence, causes, evaluation, and management of fever in postoperative adult cardiac surgical patients.

A case of rapid progression of postoperative hyperthermia: Dantrolene or not dilemma?

Malignant hyperthermia (MH) is an extremely rare and life–threatening differential diagnosis of postoperative fever. We present an 8-month-old child scheduled for elective outpatient procedure who rapidly developed high fever, tachycardia, and respiratory acidosis shortly after transfer to the postanesthesia care unit. MH hotline expert recommended administering dantrolene, but there was no evidence of hypermetabolism or lactic acidosis. The patient remained clinically stable after admission to the pediatric intensive care unit and was discharged home the next day. The fever was likely due to viral infections as confirmed by a positive result of viral polymerase chain reaction for human metapneumovirus and rhinovirus/enterovirus.

Wind, water, wound, walk--do the data deliver the dictum?

OBJECTIVE

To evaluate the teaching dictum "wind, water, wound, walk" in the modern surgical environment.

DESIGN

A retrospective cohort study.

SETTING

Hospitals enrolled in the American College of Surgeons National Surgical Quality Improvement Program.

PARTICIPANTS

We identified 11,137 patients enrolled in American College of Surgeons National Surgical Quality Improvement Program Participant Use File (2011) who were older than 18 years; underwent a general surgical procedure; and developed a postoperative pneumonia (PNA, "wind"), urinary tract infection (UTI, "water"), surgical site infection (SSI, "wound"), or venous thromboembolic event (VTE, "walk") for inclusion in the study. Patients were excluded if they had an infection present at the time of surgery or were missing information on the time of diagnosis.

RESULTS

The median day of diagnosis differed significantly according to occurrence type (median day of PNA = 5, UTI = 8, SSI = 11, and VTE = 9, p < 0.001). The sequence of occurrences diagnosed before discharge (median day of PNA = 4, UTI = 5, SSI = 7, and VTE = 5) differed from that of occurrences diagnosed following discharge (median day of PNA = 10, UTI = 14, SSI = 14, and VTE = 14). Within the predischarge and postdischarge subsets, the median day of diagnosis remained significantly different according to occurrence type (all p's < 0.001).

CONCLUSIONS

The dictum should be taught as, "wind, water, walk, wound" to reflect the timing and progression of the diagnosis of PNA, UTI, VTE, and SSI. The dictum did not reflect the timing or sequence of the occurrences in the cohort diagnosed after discharge. Educators must teach trainees to apply the dictum in the appropriate patient setting. As surgical care changes, we must continue to reassess our educational pearls to ensure that they reflect the modern reality.

Febrile response following megaprosthesis replacement for primary bone sarcoma

The presence of early postoperative fever after megaprosthesis replacement surgery is a concern for orthopedic oncologists due to the possibility of infection. The aims of the current study were to determine the incidences and patterns of fever and factors associated with its development and to determine the clinical significance of fever after megaprosthesis replacement surgery. Seventy-one patients who had undergone megaprosthesis reconstruction for previously unoperated localized lower-extremity osteosarcoma were reviewed. No patient had evidence of infection preoperatively. Mean patient age was 23.72±16.84 years (range, 6.7-74 years), and average follow-up was 59.5 months (range, 4-240 months). Five postoperative surgical wound infections (4 deep, 1 superficial) occurred on postoperative days 5, 13, 14, 20, and 21. Fevers (body temperature of 38 °C or higher) were present in 62 patients (87.3%) at some point during the first 2 postoperative weeks. Peak body temperature was observed on postoperative day 1 in 62% of the febrile patients. Of the 62 febrile patients, 94% were relieved of fever by postoperative day 5. No significant association was observed between the presence of fever and surgical wound infection. Body temperature curves in patients with infection showed that several atypical patterns, such as multiple fever peaks and persistent fever, were accompanied by physical findings within the normalization period. Fever during the first 5 postoperative days is common after megaprosthesis replacement for bone sarcomas and seems to be a normal physiologic response to surgery. However, atypical fever patterns or additional physical findings require investigation.

Atelectasis as a cause of postoperative fever: where is the clinical evidence?

BACKGROUND

Atelectasis is considered to be the most common cause of early postoperative fever (EPF) but the existing evidence is contradictory. We sought to determine if atelectasis is associated with EPF by analyzing the relevant published evidence.

METHODS

We performed a systematic search in PubMed and Scopus databases to identify studies examining the association between atelectasis and EPF.

RESULTS

A total of eight studies, including 998 cardiac, abdominal, and maxillofacial surgery patients, were eligible for analysis. Only two studies specifically examined our question, and six additional articles reported sufficient data to be included. Only one study reported a significant association between postoperative atelectasis and fever, whereas the remaining studies indicated no such association. The performance of EPF as a diagnostic test for atelectasis was also assessed, and EPF performed poorly (pooled diagnostic OR, 1.40; 95% CI, 0.92-2.12). The significant heterogeneity among the studies precluded a formal metaanalysis.

CONCLUSION

The available evidence regarding the association of atelectasis and fever is scarce. We found no clinical evidence supporting the concept that atelectasis is associated with EPF. More so, there is no clear evidence that atelectasis causes fever at all. Large studies are needed to precisely evaluate the contribution of atelectasis in EPF.

Postoperative Fever Discharge Guidelines Increase Hospital Charges Associated With Spine Surgery

BACKGROUND:

Postoperative fever is a common sequel of spine surgery. In the presence of rigid nationally mandated clinical guidelines, fever management may consume more health care resources than is reasonably appropriate.

OBJECTIVE:

To study the relationship between postoperative fever, infection rate, and hospital charges in a cohort of spine surgery patients.

METHODS:

We retrospectively reviewed 578 spine surgery patients (lumbar microdiskectomy [LMD], anterior cervical decompression and fusion [ACDF], and lumbar decompression and fusion [LDF]). Differences in length of stay and hospital charges as well as risk factors and correlation with infection and readmission rates were studied.

RESULTS:

Postoperative fever occurred in 41.7% of all spine surgery patients and more often in LDF patients (77.2%). Type of surgery was the most important variable affecting the prevalence of postoperative fever. Significant differences in length of stay were elicited between patients with and without postoperative fever in the ACDF and LMD groups and in hospital cost in the LMD group. The average length of stay was 2.41 vs 4.47 (P &lt; .01) in the LMD group, 1.67 vs 2.80 (P &lt; .05) in the ACDF group, and 5.03 vs 5.65 (P &gt; .05) in the LDF group. The average hospital charges were $16 261 vs $22 166 (P &lt; .01) in the LMD group, $26 021 vs $29 125 (P &gt; .05) in the ACDF group, and $53 627 vs $53 210 (P &gt; .05) in the LDF group. Obesity, female sex, and ≥102°F postoperative temperature were the most significant predictors of infection. Delayed discharge referable to postoperative fever did not seem to influence the infection readmission rate.

CONCLUSION:

Postoperative fever in spine surgery patients is associated with a delay in patient discharge and increases in hospital charges. Postoperative fever discharge guidelines should be regularly and publicly subjected to appropriate cost-benefit analysis.

Postoperative fever: a normal inflammatory response or cause for concern

PURPOSE

To devise a systematic diagnostic strategy displayed in algorithm format to assist advanced practice registered nurses (APRNs) in determining when postoperative fever is simply a normal inflammatory response and when further investigation is needed to rule out infection or other serious noninfectious causes of fever.

DATA SOURCES

Selected research and clinical articles.

CONCLUSIONS

Postoperative fever is often a normal inflammatory response to surgery, but it can also be a manifestation of a serious underlying infectious or noninfectious etiology. Therefore, it is important to approach each instance of postoperative fever in a systematic manner.

IMPLICATIONS FOR PRACTICE

The role of the APRN in managing surgical patients requires being able to accurately assess and evaluate the cause of postoperative fever and take action accordingly. That means taking into account a variety of factors (e.g., patient's medical history, physical examination findings, and type of surgery), so that appropriate diagnostic tests can be ordered to evaluate the cause of the postoperative fever. By being aware of the causes of postoperative fever, the APRN can also take prophylactic action to decrease the risk associated with many of these potential febrile causes.

Early postoperative fever and the "routine" fever work-up: results of a prospective study

BACKGROUND

Fever in the postoperative period frequently results in a battery of diagnostic tests in search of an etiology. We sought to evaluate the incidence and utility of extensive postoperative fever evaluations in a teaching hospital setting.

MATERIALS AND METHODS

Prospective observational study of all adult patients undergoing in-patient general surgical procedures during a 13-mo period. Patients experiencing an early postoperative fever (>100.4° F in the first 72 h) had data collected on their evaluation, the yield of the diagnostic studies, and whether an infectious diagnosis was made.

RESULTS

Of 1032 surgical procedures, 245 (23.7%) patients experienced an early postoperative fever. One hundred patients (9.7%) underwent documented fever evaluation. Thirty-five (35%) had blood cultures with no positive results among elective surgery patients. Forty-six patients (46%) had urine cultures sent, of which four infections were diagnosed (8.9%). Fifty chest radiographs were performed, but the diagnosis of pneumonia was made by only three (6.0%). Ultimately, 18 febrile patients (18%) were diagnosed with an infectious source, in nine of these patients the physical exam and clinical picture accurately diagnosed the infection without need for further testing.

CONCLUSION

Early postoperative fever is a common event and rarely caused by an infection. A brief bedside evaluation has the highest yield for determining the fever etiology, and extensive evaluations with cultures and chest imaging have little to no benefit in patients admitted for elective surgery.

Fever evaluations after colorectal surgery: identification of risk factors that increase yield and decrease cost

PURPOSE

This study was designed to evaluate the yield and cost of fever evaluations in average-risk inpatients after elective colorectal surgery.

METHODS

A 12-month, retrospective study was performed on patients who developed a postoperative fever > or = 38 degrees C after elective colorectal surgery. A positive fever evaluation was defined as a blood culture, urine culture, chest x-ray, or abdominal CT result that led to a change in patient management. Logistic regression, Fisher's exact test, and chi-squared test were used; odds ratios were calculated.

RESULTS

Of 133 patients, 26 percent had a positive evaluation. Blood culture, urine culture, chest x-ray, and CT were positive in 3, 8, 7, and 46 percent, respectively. Risk factors for a positive fever evaluation were temperature > or = 38.5 degrees C, fever evaluation after postoperative Day 6, and a clinical manifestation of systemic inflammatory response syndrome other than fever (all, P < 0.01). The cost per positive fever evaluation for the entire group, patients with 2 risk factors, or patients with 3 risk factors was $5,600, $4,200, and $2,140, respectively.

CONCLUSIONS

The current approach to fever evaluation after elective colorectal surgery is low yield and costly. High fever, late postoperative fever, and systemic inflammatory response syndrome are risk factors for a positive fever evaluation after colorectal surgery.

Prevention, Recognition, and Management of Nursing Complications in the Intraoperative and Postoperative Surgical Patient

A review of the literature focusing on postoperative complications reveals that the best available tools to the medical and surgical teams are recognition and prevention. This article highlights the more common postsurgical adverse events and discusses methods for preventing and treating these occurrences.

Extensive fever workup produces low yield in determining infectious etiology

OBJECTIVE

The study was undertaken to evaluate the use of a fever workup in women undergoing benign gynecologic procedures.

STUDY DESIGN

A retrospective chart review was performed at Jackson Memorial Hospital between 1994 and 2000. Information was abstracted from hospital and clinic records. Fever criteria was defined as 1 temperature equal to or greater than 101.5, or 2 equal to or greater than 100.4, at least 4 hours apart within a 24-hour period. Patients undergoing additional intraoperative procedures leading to increased febrile morbidity were excluded. Data abstracted included patient demographics, procedure, complications, antibiotic use, and extent of fever workup. Statistical analysis used was 2-sample t tests, Wilcoxon rank test, chi2 test, and multivariate logistic regression. Alpha level = .05.

RESULTS

The charts of 505 patients were reviewed, and 147 patients met fever criteria. All patients underwent surgery for benign conditions, abdominal hysterectomy being the most common (90%). The study population was divided into 2 groups: the noninfectious group and infectious group. These groups were determined by wound infection, pelvic abscess, blood or urine culture, ultrasound, and chest roentgen. Both groups were found to be similar with respect to demographics, surgical procedures, and postoperative complications, with the exception of body mass index (28.4 vs 31.7) and length of hospital stay (3.9 vs 5.3). Results from fever workups included positive results blood cultures (9.7%), urine culture (18.8%), and chest roentgens (14%) in this study population. We found no association between positive urine analysis and urine culture. When comparing both groups, a statistically significant difference was found with regard to maximum temperature elevation, number of days febrile, and postoperative day of maximum temperature (P < .05).

CONCLUSION

The extensive fever workup was not frequently positive in this study population. Its use and cost-effectiveness should be questioned. Therefore, the fever workup should be tailored to the individual patient.

Causes and consequences of fever complicating critical surgical illness

BACKGROUND

Fever may have malign consequences in the postoperative period. This study was performed to determine the causes and consequences of fever in critically ill surgical patients. The specific hypothesis tested is that postoperative fever is associated with adverse clinical outcomes, including increased organ dysfunction and risk of death.

METHODS

Inception-cohort study of critically ill surgical patients who manifested a core temperature of >/=38.2 degrees C for the first time. The episode of fever was monitored until resolution, which was defined as a core temperature of <38.2 degrees C for at least 72 consecutive h. Demographic data collected included age, gender, admission diagnosis, admission status (elective/emergency), severity of illness (APACHE III), the systemic inflammatory response syndrome (SIRS) score, the cumulative multiple organ dysfunction score, cause of fever (infectious/non-infectious), ICU and hospital length of stay, and mortality. The day of onset of fever in the ICU, peak temperature, ICU day of peak temperature, and duration of fever episode were recorded. All diagnostic and therapeutic interventions were recorded, including the type and duration of antibiotic therapy. Univariate results of possible significance (alpha < 0.15) were tested in logistic regression models for independence of effect upon mortality after auto-correlation was excluded by matrix correlations and the Durbin-Watson statistic. Cases where both non-infectious and infectious causes of fever were present were analyzed as part of the infectious group, whereas the cumulative MOD score was dichotomized (< 5, >/=5 points) at a value known to be associated with increased mortality.

RESULTS

Among 2,419 screened patients, 626 patients (26%) developed fever. Febrile patients were older, sicker, more likely to have undergone emergency surgery, more likely to develop organ dysfunction, and more likely to die (all, p < 0.0001). The mean day of onset of fever was day 1 and the mean peak temperature for the episode was 39.1 +/- 0.1 degrees C. For most patients, it was their only episode of fever, with a mean of 1.4 +/- 0.1 episodes/patient. Forty-six percent of febrile patients were found to have an infectious cause of fever. Nearly all patients had SIRS, and nearly all developed organ dysfunction to some degree. By logistic regression, the presence of SIRS (as opposed to fever in isolation), emergency status, higher APACHE III score and the peak temperature were associated with increased mortality, with peak temperature being the most powerful predictor in the model (OR 2.20, 95% Cl 1.57-3.19). Gender had no bearing on outcome, and there was a trend toward a protective effect from an infectious etiology of fever.

CONCLUSIONS

Postoperative fever is deleterious to critically ill patients. The magnitude of fever is a determinant of mortality, whereas an infectious etiology of fever may not be. The impacts of nosocomial infection and suppression of fever on critically surgical patients deserve further study.

Saturday night fever: finding and controlling the source of sepsis in critical illness

Fever is a daily concern in the intensive care unit. Although about half of all febrile cases are due to non-infectious causes, fear of sepsis frequently leads to diagnostic tests and escalation of therapy, including broadening antibiotic therapy. Using a case to illustrate this dilemma, we discuss the commonest non-infectious and infectious causes of fever, and suggests approaches to their management. Any unexplained fever in intensive care unit patients warrants investigation, which includes complete clinical assessment and blood cultures. When the source of fever is not immediately apparent, non-infectious and infectious causes should be considered. If stable, non-neutropenic patients should be monitored before further tests or empiric antibiotics are started. In an era of rapid emergence and spread of antimicrobial-resistant pathogens and intense scrutiny of resources, optimal diagnosis and management of patients with suspected infection entails much more than the escalation of antimicrobial therapy.